Failure to Implement Infection Surveillance and Infection Control Practices
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program as evidenced by two main deficiencies. First, during a COVID-19 outbreak spanning six months, the facility did not include residents who tested negative for COVID-19 on its case line listing, contrary to the requirements outlined in the Respiratory Virus Outbreak Toolkit. The Infection Preventionist and Director of Nursing confirmed that there was no surveillance plan in place to track and monitor residents who tested negative during the outbreak period, based on a misunderstanding of current guidance. Second, during a wound care observation for a resident with diagnoses of anemia, hypertension, and heart failure, a registered nurse did not follow established infection control practices. The nurse failed to establish a clean field, placed a soiled dressing on the bed, did not perform hand hygiene at required steps, handled a washcloth without gloves, and did not complete hand hygiene after the procedure. These actions were confirmed by the nurse during an interview, indicating a failure to prevent cross-contamination during a dressing change.